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CAUSES   OF   IMPOTENCE   ASTD   STERILITY   IN   THE   FEMALE                 289

In one case a 6-para woman, aged 46 years, was delivered of a female child
two years after the menopause. In the other case a 9-para woman, 48 years
old, became pregnant after three years of the menopause and was delivered
of a male baby. A case is also recorded in which a woman was delivered
of her last child at the age of fifty years and seven months.24 Denholm-
Young25 mentions that in Shetland and Orkney menstruation ceases nor-
mally at about the age of 60 years, and children are sometimes borne at that

2. Malformations.—Congenital malformations, such as the total occlu-
sion of tne vagina, adhesion of the labia and the tough, imperforate hymen,
are barriers to coitus, and consequently lead to sterility, but these malfor-
mations are such as can be remedied by surgical interference. ^The
congenital absence of the vagina will ordinarily render a female completely
and permanently impotent and sterile. In such cases the uterus is com-
monly non-existent. Cases have, however, been reported where an artificial
vagina had been formed by an operation. Hodgson26 records a case in
which he formed an artificial vagina in a married woman, 32 years old, who
had no vagina from her birth. Coitus was subsequently carried out
satisfactorily. Hannan27 also reports the case of a perfectly developed
woman, aged 24 years, who had normal genitalia and normal secondary sex
characteristics. The hymen was normal, but no vagina could be found and
there was no evidence of either the uterus or the ovaries on rectal
examination. The vagina appeared to be replaced by a mass of fibrous
tissue. The labia were divided from above downwards, and made into a
vagina, about 2 inches long.

2Jie_jconical cervix and the absence of the uterus, ovaries or Fallopian
tubes produce sterility, though allowing the gratification of sexual inter-

3.    Local Disease^.—The female merely plays a passive role in the act of
coitus;   Hence  the  local diseases  of the  genital organs  do  not  ordinarily
prevent sexual intercourse provided the vagina is normal, but they may
produce sterility.   IJms, the inflammatory affections of gonorrhoea! infection
involving  the  cervix,  uterus,  ovaries  and  Fallopian  tubes  often  produce
sterility.   Removal of both the ovaries owing * to pathological conditions may
not render a woman sterile, if a healthy portion of an ovary is left intact.
Displacements and tumours of the uterus may be considered as causes of
sterility, but not in all cases.    Owing to the painful and spasmodic contrac-
tion of the constrictor muscle of the vagina at the time of coitus, vaginismus
may lead to temporary impotence.   I^urther, rectovaginal fistula, ruptured
perinaeum, disorders of mensfruation, leucorrhoea and acid discharges from
the vagina may contribute 'towards sterility.

4.    General   Diseases.—General   diseases   and   a   bodily   deformity   in
women are not barriers to sexual intercourse or conception if the generative
organs   and   menstruation   are   normal.   Thus,   a   woman   suffering   from
paraplegia can become pregnant.

5.    Psychical Influences.—Hatred, fear, passion, neurotic temperament,
etc. may produce a" hysterical'fit on an attempt at copulation, and may thus
render a woman temporarily impotent especially if she happens to be a
virgin.   It is possible for a woman to be sterile or impotent with a particular
man, arid quite the opposite with another.

24.   John H. Gibertson, Brit. Med, Jour., March 17, 1917, p. 378.
•, 25.   Brit. Med. Jour., Vol. I, April 23, 1949, p. 736.

26.    Brit. Med. Jour., May 13, 1933, p. 822.

27.    Medical Press, April 2, 1947, p. 270 ; see also B. N. Sharing Jj
Vol XX, July 1951, p. 373.